Kent H. Robbins/American Interstate Corp.
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the
City Manager or any city board or committee; or any action, decision or recommendation of any city personnel defined in any
manner In this section, during the time period of the entire decision-making process on such action, decision or recommendation
that foreseeably will be heard or reviewed by the city commission, or a city board or committee. The term specifically includes the
principal as well as any employee engaged in lobbying activities. The term "Lobbyists'" has specific exclusions. Please refer
to Ordinance 2004-3435.
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NAMElO~O~Y;: UJf\S;H'(~~~ Avt.. M(;:~,
BUSINESS NAME AND ADDRESS (Number and Street) (City)
3oS-S3~-6S00 JbS-sa/-O/S-o
TELEPHONE NUMBER: FAX NUMBER:
t<'i:rf\
~lSorJ
(M .1)
Bfj A-c t4 FL 3 3 (3~_
(state1 (Zip Code)
t' t-f (20 De i) &i I/socfTH. "r.. I
EMAlL:
I. LOBBYIST RETAINED BY: r
f\(Yl~(l. lc.A-('J TNW~TL lDtlp.
NAME OF PRlNClPAL/CUENT:
1 <&ao M~ Of,q-,J tl" f... , ~ f ~\ f,r1fcH F'- 3 313 q
BUSINESS NAME AND ADDRESS (Number and Street) (Oty) f (State) (Zip Code)
30S" "7;), "'Sfo -, b
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAlL: (Optional)
Fill out this section If principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
!-{'IeiY S e tt~c..TEe~ C ~O
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
L. t toy S~ \t EG TE R.
.
II. SPECIFIC LOBBY ISSUE:
, ,t.f:S Iff t.EP "ESSftJlfl-t/~ (la tV(~~^,/~ ~VEldpHtIVT tSS<lt~ ''''\JO'fI'''~
Issue to be lobbied (Describe in detail): 01 doO eol',..,S Pc ~ ft""l> A t>jOI N INj 1>~?t: (t"t,~ S .
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
\1(STol2,G Pt.E.~e"AIION B.,1l2.D
~{ r'l,i sr~
-Bu. , V,
~otJE
otV~
tJO i\J S
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLA T RA TE OR OTHER). ,
A) LOBBYIST DISCLOSURE: (Required) hay r
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). oc) f'
o Yes &rl40: Are YOU representina a not-for-Drofit corDoration or entity without sDecial compensation or
reimbursement. Pursuant to Ordinance No. 2004-3435.
1)
Pursuant to Ordinance No. 2003-3393 Amendino Miami Beach City Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaion Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaion Contributions By LobbYists On Procurement Issues":
DYes lIrNo:
Are YOU lobbyina on a Dresent or oendina bid for aoods. eauiDment or services. or on a Dresent
or oendina award for aoods. eauioment or service?
2)
Pursuant to Ordinance No. 2003-3395 Amendino Miami Beach City Code Chapter 2. Article VII Division 5
thereof Entitled "Campaion Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
CamoaiCln Contributions By LobbYists On Real Estate Develooment Issues":
DYes 60:
Are YOU lobbyina on a pendina apDlication for a DeyeloDment Aar~m~nt Wi~h ~he C~ ~r
aDolication for chanae of zonina maD desianation or chanae to th~ i 's Fu ur Lan U e MaD?
V.
SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, UsnNG LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PR EDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN N PE ITURES MP ON DURING THE
REPORTING PERIOD.
Signature of Lobbyist
Signature of Lobbyist:
I do solemnly swear that all of e foregoing facts are true and correct and that I have read or am
familiar with the provisio ained in cti n 2-482 of Miami Beach City Code anda~C1m~~
requirements. ,,' ......... 01" ~
.:t "';C~'MISS/Ol!:", ~
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PRINCIPAL IDENTIFICATION: .r~ U""'/'7'lnS(Jra~r!'..' ()<:('~
''''''1. "(Ie ....... C<(\; ~,,,,,
/ - ^ 1111 ,.',:.rA-n:-Oi'.~",'
LY"Produced 10 r L. u V ( l/ I!.JII~ .
Form of Identification
,
Signature of Principal/Client:
.' '>;' \ ,: !ll """11
~~/~o~.d CO/;/J ~BYIST IDENTIFICATION:
'i:..~ v ....... ~
~ ....~\SSION ;:" ~
~ ... c.,CJ\,\ ~,2JdA.&tpd~ed 10
~ :' 5; '>" ~ 'i), ~ * ~ Form of Identification
~: ~. #D;2~~J~~IIY known (Lobbyist)
"~0 II . ..g::~
~-,,""9'~ -.. l;; 8o!laed~~~\0'> .it- >55~
".~:"'&8YI~~s~~~.~t&'NATURE AND STAMP OF NOTARY:
'II (!e STtll'- ""
Illfll/f Hll \11\"
State of Florida, County of Miamj,:D~de
sworn.~JOan.d.'.subscri~. ~~ m,e /_
Th~'~" 7/ ,d, ay Of..... . ' 20{2 .~
L-:7~/ . ~~
L-V'Z/ L_.' ......--
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
o Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and SUbSCrj~~e me ,/'
This LL~~~' ' . ,20gv
C--c;:'2/~ L,~
Signature of Public Notary - State of Florida
Notarization of Principal's signature
/ FOR CLER 's SE ONLY "':::L11I/1Jrt."
Annual Registration fee: [VJ Yes [ ] No Amount Pai .fIj MCR # ~Date Paid ~
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F. R\A L\ RIA-M\LOBBYIST\LOBBYIST FORM 04